1
|
Grigoriou SS, Giannaki CD, George K, Karatzaferi C, Zigoulis P, Eleftheriadis T, Stefanidis I, Sakkas GK. A single bout of hybrid intradialytic exercise did not affect left-ventricular function in exercise-naïve dialysis patients: a randomized, cross-over trial. Int Urol Nephrol 2021; 54:201-208. [PMID: 34100215 DOI: 10.1007/s11255-021-02910-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 05/31/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Cardiovascular diseases are the leading cause of mortality in end-stage renal disease (ESRD) patients, especially those receiving hemodialysis (HD) therapy. HD has many side effects that are related to patients' hearts, such as recurrent myocardial ischemia and global or segmental left-ventricular dysfunction, which is associated with intradialytic hypotension, long-term loss of systolic function, and high incidence of cardiovascular events and death. Systematic exercise training has a beneficial effect on measures of cardiovascular fitness and reducing cardiovascular risk factors in ESRD. Whether there is an acute benefit of exercise during HD on left-ventricular function is not well known. The current study aimed to investigate whether a single bout of hybrid (aerobic and resistance) intradialytic exercise could affect left-ventricular function during HD sessions. METHODS Twenty-one exercise naïve and clinically stable HD patients participated in the study. All participants completed two different HD trials on two different days, separated by 1 week: (1) standard HD and (2) HD including a single bout of hybrid intradialytic exercise. Hybrid intradialytic training included the usual intradialytic cycling followed by resistance training using elastic bands and dumbbells. Echocardiographic assessment of left-ventricular function was completed before HD, half an hour before the end of HD, and 30 min after the end of HD. RESULTS Cohort data for left-ventricular function indices were not different between trials and did not change across time in either the standard HD or HD plus exercise trial. Cohort data for the change in ejection fraction from baseline to during HD did mask considerable inter-individual variability (HD - 0 ± 15; HD plus exercise (- 2 ± 20). Despite this, the variability was not mediated by the addition of intradialytic hybrid exercise. CONCLUSION A single bout of hybrid intradialytic exercise did not affect left-ventricular function during the HD therapy. It is important to determine whether chronic exercise training could beneficially affect left-ventricular function abnormalities often observed during the HD therapy. TRIAL REGISTRATION NUMBER The study is registered at ClinicalTrials.gov (NCT01721551) as a clinical trial.
Collapse
Affiliation(s)
- Stefania S Grigoriou
- School of Physical Education, Sport Science and Dietetics, University of Thessaly, 42100, Trikala, Greece
| | | | - Keith George
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Christina Karatzaferi
- School of Physical Education, Sport Science and Dietetics, University of Thessaly, 42100, Trikala, Greece
| | - Paris Zigoulis
- Department of Medicine, School of Health Science, University of Thessaly, Larissa, Greece
| | | | - Ioannis Stefanidis
- Department of Medicine, School of Health Science, University of Thessaly, Larissa, Greece
| | - Giorgos K Sakkas
- School of Physical Education, Sport Science and Dietetics, University of Thessaly, 42100, Trikala, Greece.
- School of Sports and Health Sciences, Cardiff Metropolitan University, Cardiff, UK.
| |
Collapse
|
2
|
Kaptein MJ, Kaptein JS, Nguyen CD, Oo Z, Thwe PP, Thu MB, Kaptein EM. Changes in cardiac output with hemodialysis relate to net volume balance and to inferior vena cava ultrasound collapsibility in critically ill patients. Ren Fail 2020; 42:179-192. [PMID: 32050836 PMCID: PMC7034082 DOI: 10.1080/0886022x.2020.1726384] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Cardiac output may increase after volume administration with relative intravascular volume depletion, or after ultrafiltration (UF) with relative intravascular volume overload. Assessing relative intravascular volume using respiratory/ventilatory changes in inferior vena cava (IVC) diameters may guide volume management to optimize cardiac output in critically ill patients requiring hemodialysis (HD) and/or UF.We retrospectively studied 22 critically ill patients having relative intravascular volume assessed by IVC Collapsibility Index (IVC CI) = (IVCmax-IVCmin)/IVCmax*100%, within 24 h of cardiac output measurement, during 37 intermittent and 21 continuous HD encounters. Cardiac output increase >10% was considered significant. Net volume changes between cardiac outputs were estimated from "isonatremic volume equivalent" (0.9% saline) gains and losses.Cardiac output increased >10% in 15 of 42 encounters with IVC CI <20% after net volume removal, and in 1 of 16 encounters with IVC CI ≥20% after net volume administration (p = 0.0136). All intermittent and continuous HD encounters resulted in intradialytic hypotension. Net volume changes between cardiac output measurements were significantly less (median +1.0 mL/kg) with intractable hypotension or vasopressor initiation, and net volume removal was larger (median -22.9 mL/kg) with less severe intradialytic hypotension (p < 0.001). Cardiac output increased >10% more frequently with least severe intradialytic hypotension and decreased with most severe intradialytic hypotension (p = 0.047).In summary, cardiac output may increase with net volume removal by ultrafiltration in some critically ill patients with relative intravascular volume overload assessed by IVC collapsibility. Severe intradialytic hypotension may limit volume removal with ultrafiltration, rather than larger volume removal causing severe intradialytic hypotension.
Collapse
Affiliation(s)
- Matthew J Kaptein
- Department of Medicine, Division of Nephrology, Loma Linda University Medical Center, Loma Linda, CA, USA.,Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - John S Kaptein
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - Christopher D Nguyen
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - Zayar Oo
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - Phyu Phyu Thwe
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - Myint Bo Thu
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| | - Elaine M Kaptein
- Department of Medicine, Division of Nephrology, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
3
|
Burlacu A, Genovesi S, Basile C, Ortiz A, Mitra S, Kirmizis D, Kanbay M, Davenport A, van der Sande F, Covic A. Coronary artery disease in dialysis patients: evidence synthesis, controversies and proposed management strategies. J Nephrol 2020; 34:39-51. [PMID: 32472526 DOI: 10.1007/s40620-020-00758-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/23/2020] [Indexed: 12/31/2022]
Abstract
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality among patients with end-stage renal disease (ESRD). Clustering of traditional atherosclerotic and non-traditional risk factors drive the excess rates of coronary and non-coronary CVD in this population. The incidence, severity and mortality of coronary artery disease (CAD) as well as the number of complications of its therapy is higher in dialysis patients than in non-chronic kidney disease patients. Given the lack of randomized clinical trial evidence in this population, current practice is informed by observational data with a significant potential for bias. Furthermore, guidelines lack any recommendation for these patients or extrapolate them from trials performed in non-dialysis patients. Patients with ESRD are more likely to be asymptomatic, posing a challenge to the correct identification of CAD, which is essential for appropriate risk stratification and management. This may lead to "therapeutic nihilism", which has been associated with worse outcomes. Here, the ERA-EDTA EUDIAL Working Group reviews the diagnostic work-up and therapy of chronic coronary syndromes, unstable angina/non-ST elevation and ST-elevation myocardial infarction in dialysis patients, outlining unclear issues and controversies, discussing recent evidence, and proposing management strategies. Indications of antiplatelet and anticoagulant therapies, percutaneous coronary intervention and coronary artery bypass grafting are discussed. The issue of the interaction between dialysis session and myocardial damage is also addressed.
Collapse
Affiliation(s)
- Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Simonetta Genovesi
- Nephrology Unit, San Gerardo Hospital, Monza, Italy, University of Milan-Bicocca, Milan, Italy
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, Via Battisti 192, Acquaviva delle Fonti, 74121, Taranto, Italy. .,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy.
| | - Alberto Ortiz
- FRIAT and REDINREN, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
| | - Sandip Mitra
- Manchester Academy of Health Sciences Centre, Manchester University Hospitals Foundation Trust and University of Manchester, Oxford Road, Manchester, UK
| | | | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Andrew Davenport
- Division of Medicine, UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
| | - Frank van der Sande
- Division of Nephrology, Department of Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center-'C.I. Parhon' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania.,The Academy of Romanian Scientists (AOSR), Bucharest, Romania
| | | |
Collapse
|
4
|
Silva VB, Macedo TA, Braga TMS, Silva BC, Graciolli FG, Dominguez WV, Drager LF, Moysés RM, Elias RM. High Dialysate Calcium Concentration is Associated with Worsening Left Ventricular Function. Sci Rep 2019; 9:2386. [PMID: 30787343 PMCID: PMC6382760 DOI: 10.1038/s41598-019-38887-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/11/2019] [Indexed: 12/05/2022] Open
Abstract
Dialysate calcium concentration (d[Ca]) might have a cardiovascular impact in patients on haemodialysis (HD) since a higher d[Ca] determines better hemodynamic tolerability. We have assessed the influence of d[Ca] on global longitudinal strain (GLS) by two-dimensional echocardiography using speckle-tracking imaging before and in the last hour of HD. This is an observational crossover study using d[Ca] 1.75 mmol/L and 1.25 mmol/L. Ultrafiltration was the same between interventions; patients aged 44 ± 13 years (N = 19). The 1.75 mmol/L d[Ca] was associated with lighter drop of blood pressure. Post HD serum total calcium was higher with d[Ca] 1.75 than with 1.25 mmol/L (11.5 ± 0.8 vs. 9.1 ± 0.5 mg/dL, respectively, p < 0.01). In almost all segments strain values were significantly worse in the peak HD with 1.75 mmol/L d[Ca] than with 1.25 mmol/L d[Ca]. GLS decreased from −19.8 ± 3.7% at baseline to −17.3 ± 2.9% and −16.1 ± 2.6% with 1.25 d[Ca] and 1.75 d[Ca] mmol/L, respectively (p < 0.05 for both d[Ca] vs. baseline and 1.25 d[Ca] vs. 1.75 d[Ca] mmol/L). Factors associated with a worse GLS included transferrin, C-reactive protein, weight lost, and post dialysis serum total calcium. We concluded that d[Ca] of 1.75 mmol/L was associated with higher post dialysis serum calcium, which contributed to a worse ventricular performance. Whether this finding would lead to myocardial stunning needs further investigation.
Collapse
Affiliation(s)
- V B Silva
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - T A Macedo
- Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - T M S Braga
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - B C Silva
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - F G Graciolli
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - W V Dominguez
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - L F Drager
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.,Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - R M Moysés
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.,Universidade Nove de Julho (UNINOVE), São Paulo, Brazil
| | - R M Elias
- Nephrology Service, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil. .,Universidade Nove de Julho (UNINOVE), São Paulo, Brazil.
| |
Collapse
|
5
|
Debowska M, Poleszczuk J, Dabrowski W, Wojcik-Zaluska A, Zaluska W, Waniewski J. Impact of hemodialysis on cardiovascular system assessed by pulse wave analysis. PLoS One 2018; 13:e0206446. [PMID: 30388141 PMCID: PMC6279117 DOI: 10.1371/journal.pone.0206446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 10/13/2018] [Indexed: 01/13/2023] Open
Abstract
Valuable information about cardiovascular system can be derived from the shape of aortic pulse wave being the result of reciprocal interaction between heart and vasculature. Pressure profiles in ascending aorta were obtained from peripheral waveforms recorded non-invasively (SphygmoCor, AtCor Medical, Australia) before, during and after hemodialysis sessions performed after 3-day and 2-day interdialytic intervals in 35 anuric, prevalent hemodialysis patients. Fluid status was assessed by Body Composition Monitor (Fresenius Medical Care, Bad Homburg, Germany) and online hematocrit monitoring device (CritLine, HemaMetrics, Utah). Systolic pressure and ejection duration decreased during dialysis. Augmentation index remained stable at 30 ± 13% throughout hemodialysis session despite the decrease of augmented pressure and pulse height. Subendocardial viability ratio (SEVR) determined after 3-day and 2-day interdialytic intervals increased during the sessions by 43.8 ± 26.6% and 26.1 ± 25.4%, respectively. Hemodialysis performed after 3-day and 2-day interdialytic periods reduced significantly overhydration by 2.4 ± 1.0 L and 1.8 ± 1.2 L and blood volume by 16.3 ± 9.7% and 13.7 ± 8.9%, respectively. Intradialytic increase of SEVR correlated with ultrafiltration rate (R = 0.39, p-value < 0.01), reduction in overhydration (R = -0.57, p-value < 0.001) and blood volume drop (R = -0.38, p-value < 0.01). The strong correlation between the decrease of overhydration during hemodialysis and increase in SEVR confirmed that careful fluid management is crucial for proper cardiac function. Hemodialysis affected cardiovascular system with the parameters derived from pulse-wave-analysis (systolic and augmented pressures, pulse height, ejection duration, SEVR) being significantly different at the end of dialysis from those before the session. Combination of pulse-wave-analysis with the monitoring of overhydration provides a new insight into the impact of hemodialysis on cardiovascular system.
Collapse
Affiliation(s)
- Malgorzata Debowska
- Department for Mathematical Modeling of Physiological Processes, Nalecz
Institute of Biocybernetics and Biomedical Engineering, Polish Academy of
Sciences, Warsaw, Poland
| | - Jan Poleszczuk
- Department for Mathematical Modeling of Physiological Processes, Nalecz
Institute of Biocybernetics and Biomedical Engineering, Polish Academy of
Sciences, Warsaw, Poland
| | - Wojciech Dabrowski
- Department of Anesthesiology and Intensive Therapy, Medical University of
Lublin, Lublin, Poland
| | - Alicja Wojcik-Zaluska
- Department of Physical Therapy and Rehabilitation, Medical University of
Lublin, Lublin, Poland
| | - Wojciech Zaluska
- Department of Nephrology, Medical University of Lublin, Lublin,
Poland
| | - Jacek Waniewski
- Department for Mathematical Modeling of Physiological Processes, Nalecz
Institute of Biocybernetics and Biomedical Engineering, Polish Academy of
Sciences, Warsaw, Poland
| |
Collapse
|
6
|
Mayer CC, Matschkal J, Sarafidis PA, Hagmair S, Lorenz G, Angermann S, Braunisch MC, Baumann M, Heemann U, Wassertheurer S, Schmaderer C. Association of Ambulatory Blood Pressure with All-Cause and Cardiovascular Mortality in Hemodialysis Patients: Effects of Heart Failure and Atrial Fibrillation. J Am Soc Nephrol 2018; 29:2409-2417. [PMID: 30045925 DOI: 10.1681/asn.2018010086] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 07/03/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Evidence on the utility of ambulatory BP monitoring for risk prediction has been scarce and inconclusive in patients on hemodialysis. In addition, in cardiac diseases such as heart failure and atrial fibrillation (common among patients on hemodialysis), studies have found that parameters such as systolic BP (SBP) and pulse pressure (PP) have inverse or nonlinear (U-shaped) associations with mortality. METHODS In total, 344 patients on hemodialysis (105 with atrial fibrillation, heart failure, or both) underwent ambulatory BP monitoring for 24 hours, starting before a dialysis session. The primary end point was all-cause mortality; the prespecified secondary end point was cardiovascular mortality. We performed linear and nonlinear Cox regression analyses for risk prediction to determine the associations between BP and study end points. RESULTS During the mean 37.6-month follow-up, 115 patients died (47 from a cardiovascular cause). SBP and PP showed a U-shaped association with all-cause and cardiovascular mortality in the cohort. In linear subgroup analysis, SBP and PP were independent risk predictors and showed a significant inverse relationship to all-cause and cardiovascular mortality in patients with atrial fibrillation or heart failure. In patients without these conditions, these associations were in the opposite direction. SBP and PP were significant independent risk predictors for cardiovascular mortality; PP was a significant independent risk predictor for all-cause mortality. CONCLUSIONS This study provides evidence for the U-shaped association between peripheral ambulatory SBP or PP and mortality in patients on hemodialysis. Furthermore, it suggests that underlying cardiac disease can explain the opposite direction of associations.
Collapse
Affiliation(s)
- Christopher C Mayer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria; .,Institute for Analysis and Scientific Computing, Vienna University of Technology, Vienna, Austria
| | - Julia Matschkal
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany
| | - Pantelis A Sarafidis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece; and
| | - Stefan Hagmair
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria.,Institute for Analysis and Scientific Computing, Vienna University of Technology, Vienna, Austria
| | - Georg Lorenz
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany
| | - Susanne Angermann
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany
| | - Matthias C Braunisch
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany
| | - Marcus Baumann
- Internistische Fachklinik Dr. Steger, Nuremberg, Germany
| | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany
| | - Siegfried Wassertheurer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria.,Institute for Analysis and Scientific Computing, Vienna University of Technology, Vienna, Austria
| | - Christoph Schmaderer
- Department of Nephrology, Technical University of Munich, Klinkum rechts der Isar, Munich, Germany;
| |
Collapse
|
7
|
Loutradis C, Sarafidis PA, Papadopoulos CE, Papagianni A, Zoccali C. The Ebb and Flow of Echocardiographic Cardiac Function Parameters in Relationship to Hemodialysis Treatment in Patients with ESRD. J Am Soc Nephrol 2018; 29:1372-1381. [PMID: 29592914 PMCID: PMC5967760 DOI: 10.1681/asn.2017101102] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular disease is the leading cause of mortality in patients receiving hemodialysis. Cardiovascular events in these patients demonstrate a day-of-week pattern; i.e., they occur more commonly during the last day of the long interdialytic interval and the first session of the week. The hemodialysis process causes acute decreases in cardiac chamber size and pulmonary circulation loading and acute diastolic dysfunction, possibly through myocardial stunning and other non-myocardial-related mechanisms; systolic function, in contrast, is largely unchanged. During interdialytic intervals volume overload, acid-base, and electrolyte shifts, as well as arterial and myocardial wall changes, result in dilatation of right cardiac chambers and pulmonary circulation overload. Recent studies suggest that these alterations are more extended during the long interdialytic interval or the first dialysis session of the week and are associated with excess volume overload or removal, respectively, thus adding a mechanism for the day-of-week pattern of mortality in patients receiving hemodialysis. This review summarizes the existing data from echocardiographic studies of cardiac morphology and function during the hemodialysis session, as well as during the interdialytic intervals.
Collapse
Affiliation(s)
| | | | - Christodoulos E Papadopoulos
- 3rd Department of Cardiology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; and
| | | | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
| |
Collapse
|